100+ Free ABP Pediatric Palliative Practice Questions

Pediatric Pain Assessment and Management

Age- and cognition-appropriate pain scales (FLACC, r-FLACC, Wong-Baker FACES, NRS, NIPS, N-PASS, PIPP-R), WHO 2-step pediatric pain ladder (replaced 3-step in 2012), preferred opioids (morphine, hydromorphone), codeine and tramadol Black Box (FDA 2017, CYP2D6), methadone (long half-life, QTc, NMDA), opioid rotation and equianalgesic conversions, opioid-induced neurotoxicity (myoclonus, hyperalgesia, delirium), adjuvants (gabapentinoids, sub-anesthetic ketamine, lidocaine, dexmedetomidine, clonidine), PCA safety, transdermal fentanyl heat warning, sucrose plus non-nutritive sucking for neonatal procedural pain.

Symptom Management Beyond Pain

Dyspnea (low-dose opioid first-line; opioid plus benzodiazepine for end-of-life dyspnea with anxiety), nausea/vomiting (5-HT3 antagonists, NK1 antagonists, dexamethasone for ICP-driven, olanzapine and haloperidol for refractory CINV, scopolamine), agitation/delirium (low-dose haloperidol or atypicals; benzodiazepines can paradoxically worsen delirium), terminal secretions/death rattle (glycopyrrolate, hyoscine — limited evidence; positioning), constipation (osmotic plus stimulant prophylaxis; methylnaltrexone for OIC), seizures (buccal/intranasal/SC midazolam, levetiracetam), pruritus (cholestasis: rifampin, sertraline, cholestyramine), fatigue (low-dose stimulants), insomnia (sleep hygiene, melatonin), appetite (cyproheptadine, megestrol).

Communication with Children and Families

SPIKES protocol for breaking bad news, NURSE statements (Name/Understand/Respect/Support/Explore) for empathy, REMAP/VitalTalk and the Serious Illness Conversation Guide for goals of care, developmentally appropriate disclosure (death concept ages: 0-2 separation; 3-6 magical thinking/reversible; 6-9 universality and irreversibility; 9+ adult understanding), use of concrete language ('died,' avoid 'passed away/lost/sleep'), best/worst/most-likely prognostic framing, parental presence at resuscitation, family meetings, Voicing My CHOiCES adolescent ACP, language interpreter use, exploring protective silence with parents.

End-of-Life Care and the Dying Process

Anticipated trajectory and parallel planning (Together for Short Lives), withdrawal of life-sustaining therapy and compassionate extubation (paralytics CONTRAINDICATED — mask distress), characteristic last-hours signs (mottling, cool extremities, decreased UOP, Cheyne-Stokes, terminal lucidity, secretions), palliative sedation under doctrine of double effect, withholding/withdrawal of artificial nutrition and hydration, after-death care (memory making — handprints, photos, hair locks; Now I Lay Me Down to Sleep), perinatal palliative care for poor-prognosis fetal diagnoses, NICU palliative care, comfort feeding.

Grief and Bereavement

Anticipatory grief (begins at diagnosis), prolonged grief disorder DSM-5-TR (added March 2022; adult 12+ months, child/adolescent 6+ months with intense daily yearning + ≥3 of 8 symptoms causing impairment), Worden's Four Tasks of Mourning (accept reality, process pain, adjust to environment, find enduring connection), continuing bonds, sibling support (peer/family/school re-entry), bereavement follow-up (Medicare hospice standard 13 months including anniversary contact), risk factors for complicated grief, child grief 'puddle jumps,' bereaved parent peer support (Compassionate Friends).

Ethics and Decision-Making

Informed assent (developmentally appropriate, ~age 7+) plus parental permission, Roth-Appelbaum capacity (understand, appreciate, reason, communicate choice), surrogate decision-making (best-interest standard for never-capable; substituted judgment for previously capable), parental refusal and Diekema harm-principle threshold, 'futility'/potentially inappropriate interventions (AAP/ATS/SCCM joint statement; ethics consult and dispute resolution), POLST/Pediatric POLST/POLP, AND vs DNR (AAP 2017 Limitations of Treatment), palliative sedation and double effect, prohibition of pediatric PAS/euthanasia in all US jurisdictions, individualized goals for trisomy 13/18.

Hospice Eligibility and Models of Care

Standard hospice (Medicare model): two-physician certification of 6-month-or-less prognosis if disease runs expected course, traditionally with waiver of curative treatment for the terminal diagnosis. Concurrent Care for Children Requirement: ACA Section 2302 (2010) — children under 21 on Medicaid/CHIP can receive hospice services concurrently with curative/disease-modifying treatment. Models: primary palliative care vs specialty consultative palliative care vs concurrent care vs hospice. Early integration at diagnosis (Temel 2010 evidence base).

Spiritual Care and Cultural Humility

FICA Spiritual History tool (Faith, Importance, Community, Address in care), HOPE and SPIRIT alternates, chaplaincy referral for spiritual distress, cultural humility (Tervalon & Murray-García — lifelong self-reflection, family as expert on own values, attention to power) versus cultural competence, cross-cultural disclosure conflicts (Ask-Tell-Ask), qualified medical interpreters for LEP families (in-person preferred for serious news; never use children as interpreters), variation in language preferences for death/dying.

Self-Care and Team Wellness

Moral distress (Jameton, 1984: knowing the right action but constrained from acting), secondary traumatic stress, compassion fatigue, and burnout in pediatric palliative providers. Multimodal mitigation: peer support, structured death debriefs, Schwartz Rounds, mentorship/supervision, manageable workload, EAP/professional counseling, personal practices (sleep, exercise, mindfulness, social support), team rituals after deaths, normalization of clinician grief, system-level changes (staffing/scheduling).